Observations: Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712
Based on document review and interview, the facility failed to meet fire drill requirements for three of four quarters.
Findings include:
Document review on February 22, 2024, at 10:29 a.m., revealed the following quarters and shifts lacked fire drills: A. (10:29 a.m.) Second quarter, second shift; B. (10:29 a.m.) Third quarter, third shift; C. (10:29 a.m.) Fourth quarter, first shift.
Interview with the maintenance supervisor on February 22, 2024, at 10:29 a.m., confirmed the deficiencies.
| | Plan of Correction - To be completed: 04/15/2024
This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are legal or factually correct. This plan of correction is not meant to establish a standard of care, contract, obligation or position. Edinboro Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding, please accept this plan of correction as Edinboro Manor's credible allegation of compliance. All residents received appropriate care and services to meet their needs on all identified days and there was no direct correlation to an individual resident.
Fire Drills shall be conducted quarterly on each shift to familiarize the facilities personnel (nurses, interns, maintenance, and administrative staff) with the signals and emergency action required under varied conditions. Edinboro Manor has policies and procedures in place to comply with NFPA requirements.
Maintenance will be in-serviced on the fire drill requirements and the proper documentation requirements for the Fire drills by March 22.
An audit will be done to ensure fire drills are conducted appropriately. We will monitor for two months each shift has a fire drill.
The administrator will monitor the fire alarm drills and any deficiencies will be reported to QAPI.
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